Quick Guides Vestibular Diagnosis and Treatment:

VNG - Balance Testing Quick Guides Vestibular Diagnosis and Treatment: A Physical Therapy Approach Dix-Hallpike Test for Diagnosis of BPPV Epley Canalith Repositioning Procedure (CRP) Semont Maneuver for Posterior Canal (L) BPPV Semont Maneuver for Posterior Canal (R) BPPV Semont Maneuver for Anterior Canal (L) BPPV Semont Maneuver for Anterior Canal (R) BPPV Roll Test for Diagnosis of Horizontal Canal BPPV Lempert 360 Roll for Horizontal Canal BPPV Gufoni Maneuver for Left Lateral Canal BPPV Vannucchi-Asprella Maneuver for Right Lateral canal BPPV Brandt-Daroff Exercises 8029327-2 - 05/2014

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Dix-Hallpike Test for Diagnosis of BPPV Dix-Hallpike test performed to the right: Begin with patient seated, wearing goggles, with Quickly lay the patient back with head turned 45º head turned 45º to the right and hanging approximately 20º Dix-Hallpike test performed to the left: Begin with patient seated, wearing goggles, with Quickly lay the patient back with head turned 45º head turned 45º to the left and hanging approximately 20º Precautions: Before performing any positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. Page 1 of 3

It is important to remember that the consistency of fluid inside the vestibular system is relatively viscous; therefore, you should allow sufficient time within each of the Dix-Hallpike maneuvers for the otoconia to achieve maximum displacement. This condition may also be responsible for a delayed onset of nystagmus. It is most helpful to utilize Frenzel lenses or VNG while performing CRT. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus. It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide the patient with postural support in this situation. It is common for the patient to tell you during the intake interview which ear is affected and will describe accurately the symptoms of BPPV. Use this information to determine which ear is likely the affected ear. ALWAYS test both ears- even if the patient complains of only one side being affected. Procedure: Begin with the patient sitting length-wise on the examination table. Place the Frenzel/VNG goggles on the patient. Have the patient turn his head to a 45º angle toward the side that you suspect to be affected (the affected side). While maintaining the 45º head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20º. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE. Hold this position for 30-60 seconds or until nystagmus has subsided. Guide the patient back into a sitting position. Allow 30-60 seconds in the sitting position to allow for the patient to recover. Have the patient turn his head 90º toward the unaffected side, so that the head is at a 45º angle toward the unaffected side. While maintaining the 45º head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20º. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE. Hold this position for 30-60 seconds or until nystagmus has subsided. Guide the patient back into a sitting position. Maintain postural support until the patient is physically stable. References: 1) Dix MR, Hallpike CS. Pathology, symptoms and diagnosis of certain disorders of the vestibular system. Proc R Soc Med. 1952;45:341-354 2) Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613. Page 2 of 3

Posterior Canalithiasis Perception of vertigo often occurs in conjunction with the nystagmus. Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) Recommended treatment is the Epley Maneuver of the affected side. Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises. Posterior Cupulothiasis Perception of vertigo may subside even though nystagmus is still present. Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) Recommended treatment is the Semont Liberatory Maneuver. An alternative treatment is Brandt-Daroff Exercises. Anterior Canalathiasis Perception of vertigo often occurs in conjunction with the nystagmus. Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) Recommended treatment is the Epley CRP Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises. Anterior Cupulothiasis Perception of vertigo may subside even though nystagmus is still present. Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) Recommended treatment is the Semont Liberatory Maneuver. An alternative treatment is Brandt-Daroff Exercises. Page 3 of 3

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Epley Canalith Repositioning Procedure (also known as CRP) Epley Maneuver for right posterior canal BPPV: Begin with patients head turned 45 degrees toward the affected side. Bring to supine position with head turned toward affected side Rotate the patients head 90 degrees toward the unaffected side Guide the patient to the side lying position with their nose pointing to the ground While keeping the head in 45º, tucked position, return the patient to seated position. Page 1 of 3

Helpful Hints: It is most helpful to utilize Frenzel lenses or VNG while performing CRT. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus. Before performing any positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. Efficacy of the procedure is increased to >90% if CRP is performed twice in rapid succession. It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide postural support to the patient. It is important to watch for changes in the nystagmus upon completion of the procedure: a reversal of nystagmus indicates that the otoconia fell back into the canal; an upbeat nystagmus indicates that the otoconia fell back into the cupula. Procedure: Begin with the patient sitting length-wise on the examination table. Place the Frenzel/VNG goggles on the patient. Have the patient turn his head to a 45º angle toward the side that you are going to treat (the affected side). While maintaining the 45º head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20º. IT IS IMPERATIVE TO PROVIDE CERVIAL SUPPORT DURING THIS PORTION OF THE PROCEDURE. Hold this position for 30-60 seconds. Maintain the 20º head extension and rotate the patient s head 90º toward the unaffected side so that the patient s head is approximately 45º toward the unaffected side. Hold this position for 30-60 seconds. While still maintaining the 45º head position, guide the patient into a side-lying position on the shoulder of the unaffected side. The patient s nose should be pointed toward the floor. Hold this position for 30-60 seconds. Instruct the patient to tuck his chin and maintain the 45º head position. Guide the patient back into a sitting position while ensuring that the patient s head remains at the 45º angle and the chin remains tucked. **Refer to the attachment in attempting to diagnose affected ear and canal. References: 1) Epley J. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404 2) Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J Otol. 1999;20:465-470 3) Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional vertigo. J Otolaryngol 2001;30:295-299. Page 2 of 3

Posterior Canalithiasis CRP in the Treatment of BPPV Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) that is less than one minute in duration Recommended treatment is the Epley Maneuver of the affected side. Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises. Posterior Cupulothiasis Evidenced by an upbeat, torsional nystagmus (torsion toward the affected side) that is greater than one minute in duration Recommended treatment is the Semont Liberatory Maneuver. Alternative treatments might include Brandt-Daroff Exercises or the Epley CRP. Anterior Canalathiasis Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) that is less than one minute in duration Recommended treatment is the Epley CRP performed on the opposite side of the affected ear. Alternative treatments might include the Semont Liberatory Maneuver or Brandt-Daroff Exercises. Anterior Cupulothiasis Evidenced by a downbeat, torsional nystagmus (torsion toward the affected side) that is greater than one minute in duration Recommended treatment is the Semont Liberatory Maneuver. Alternative treatments might include Brandt-Daroff Exercises or the Epley CRP. Page 3 of 3

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Semont Maneuver for Posterior Canal BPPV Treatment of the left posterior canal: Turn the head 45 degrees to the right Rapidly move into side lying position Rapidly move to patients unaffected side on the affected side with the nose 45 degrees down Helpful Hints: Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If any possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. The patient should experience vertigo when moved to the face-down position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris. Procedure: Begin with the patient sitting on the examination table, facing the examiner, with the patient s head turned away from the affected side at a 45º angle. Guide the patient into a side-lying position toward the affected side. (This should be a rapid movement and the patient s nose should be pointing upward.) Hold this position for 2-3 minutes. While maintaining the 45º head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient s nose should be pointing downward toward the table.) Hold this position for 3-5 minutes. Guide the patient back into a sitting position. References: 1) Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3 2) Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613. Page 1 of 1

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Semont Maneuver for Posterior Canal BPPV Treatment of the right posterior canal: Turn the head 45 degrees to the left Rapidly move into side lying position Rapidly move to patients unaffected side on the affected side with the nose 45 degrees down Helpful Hints: Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If any possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. The patient should experience vertigo when moved to the face-down position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris. Procedure: Begin with the patient sitting on the examination table, facing the examiner, with the patient s head turned away from the affected side at a 45º angle. Guide the patient into a side-lying position toward the affected side. (This should be a rapid movement and the patient s nose should be pointing upward.) Hold this position for 2-3 minutes. While maintaining the 45º head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient s nose should be pointing downward toward the table.) Hold this position for 3-5 minutes. Guide the patient back into a sitting position. References: 1) Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3 Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Page 1 of 1

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Semont Maneuver for Anterior Canal BPPV Treatment of the left anterior canal: Turn the head 45 degrees to the left Rapidly move into side lying position Rapidly move to patients unaffected on the affected side side with the nose 45 degrees down Helpful Hints: Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If any possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. The patient should experience vertigo when moved to the face-down position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris. Procedure: Begin with the patient sitting on the examination table, facing the examiner, with the patient s head turned toward the affected side at a 45º angle. Guide the patient into a side-lying position on the affected side. (This should be a rapid movement and the patient s nose should be pointing downward.) Hold this position for 2-3 minutes. While maintaining the 45º head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient s nose should be pointing upward.) Hold this position for 3-5 minutes. Guide the patient back into a sitting position. References: 1) Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3 2) Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613. Page 1 of 1

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Semont Maneuver for Anterior Canal BPPV Treatment of the right anterior canal: Turn the head 45 degrees to the right Rapidly move into side lying position Rapidly move to patients unaffected side on the affected side with the nose 45 degrees upward Helpful Hints: Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. The patient should experience vertigo when moved to the face-down position. If not, it is often useful to perform a slight headshake in an effort to loosen otolithic debris. Procedure: Begin with the patient sitting toward the side of the examination table with the patient s head turned toward the affected side at a 45º angle. Guide the patient into a side-lying position toward the affected side. (This should be a rapid movement and the patient s nose should be pointing downward.) Hold this position for 2-3 minutes. While maintaining the 45º head position, guide the patient in a continuous motion from side-lying on the affected side to side-lying on the unaffected side. (The patient s nose should be pointing upward.) Hold this position for 3-5 minutes. Guide the patient back into a sitting position. References: 1) Semont, Freyss G, Vitte E. Curing the BPPV with a liberative maneuver. Adv Otorhinolaryngol. 1998;42:290-3 2) Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613. Page 1 of 1

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Roll Test for Diagnosis of Horizontal Canal BPPV Head roll to the right Head roll to the left Helpful Hints: Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. It is important to remember that the consistency of fluid inside the vestibular system is relatively viscous; therefore, you should allow sufficient time within each of the positions for the otoconia to achieve maximum displacement. This condition may also be responsible for a delayed onset of nystagmus. It is most helpful to utilize Frenzel lenses or VNG when performing positional maneuvers. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus. It is common for the patient to tell you during the intake interview which ear is affected and will describe accurately the symptoms of BPPV. Use this information to determine which ear is likely the affected ear. ALWAYS test both ears- even if the patient complains of only one side being affected. Patients are often very sensitive to horizontal canal BPPV, resulting in severe dizziness and vomiting. If the patient reacts violently during the roll test, immediately turn the patient to the opposite side and perform a Lempert 360º roll. Page 1 of 2

Procedure: Begin with the patient sitting length-wise on the examination table. Place the Frenzel/VNG goggles on the patient. Guide the patient into supine position. A slight elevation of the head (approximately 20º) is helpful. Have the patient turn his head 90º to either side. If the patient does not have enough cervical flexibility to provide maximum otoconia displacement, have the patient roll onto his shoulder. Carefully observe whether nystagmus is present. Make note of the severity and the direction of the nystagmus. Guide the patient back into a neutral, supine position. Turn the patient s head 90º to the opposite side (roll onto the shoulder if necessary). Again observe whether there is nystagmus; if so, make note of the severity and direction of the nystagmus. Guide the patient back into neutral, supine position. Results: Geotropic nystagmus - nystagmus is worse on the affected side and beats toward the ground. Best treated with the Lempert 360º roll. Acceptable alternative treatments are the Gufoni maneuver and forced prolonged positioning Apogeotropic nystagmus nystagmus is worse on the unaffected side and beats away from the ground. Best treated by first converting the nystagmus to geotropic and then performing the Lempert 360º roll. Acceptable alternative treatments are head thrust, Gufoni maneuver, Vannucchi-Asprella and forced prolonged positioning. References: 1) Korres S and others. Occurrence of semicircular canal involvement in Benign Paroxysmal Positional Vertigo. Otol Neurotol 23:926-932, 2002 2) Gans RE: Evaluating the Dizzy Patient: Establishing Clinical Pathways. Hearing Review 1999; 6 (6): 45-47. 3) Fife TD. Recognition and management of horizontal canal benign positional vertigo. Am J Otol 1998;19:345-351 Page 2 of 2

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Lempert 360º Roll for Horizontal Canal BBPV Treatment of the left horizontal canal: Roll the patient s body toward the unaffected side Roll the patient into the prone position Roll the patient s body toward the affected side Helpful Hints: Utilizing VNG while performing this maneuver is recommended to verify that the treatment is effective. If the treatment is successful, the nystagmus will beat in the same direction throughout the procedure. The success rate of this procedure in the treatment of horizontal canal BPPV is very high and success is usually immediate. If the procedure is successful, the patient may not exhibit symptoms during the last steps of the procedure. If the patient does not show marked improvement upon completion of the procedure, you should repeat the procedure. If there is still no improvement, it is possible that the wrong ear has been treated. It is important that the patient maintain the 20º head position; otherwise, it is possible for the otoconia to reverse direction within the horizontal canal during the procedure. Refer to attached chart for specific details regarding diagnosis and treatment of each nystagmus condition. The patient s compliant will often be that they experience dizziness when they turn their head in bed without turning their body. Page 1 of 3

Procedure: Begin by having the patient lay in supine position with the head elevated at approximately 20º. Roll the patient onto the shoulder of the unaffected side. Hold this position for 30-60 seconds. Roll the patient into the prone position maintaining the 20º head position (this will require the patient to hang their head off the table as illustrated). Hold this position for 30-60 seconds. Next, roll the patient onto their affected side while maintaining the 20º head position. Hold this position for 30-60 seconds. Guide the patient back into a sitting position. References: 1) Lempert T, Tiel-Wilck K. A positional maneuver for treatment of horizontal canal benign positional vertigo. Laryngoscope 1996;106:476-478. 2) Fife TD. Recognition and management of horizontal canal benign positional vertigo. Am J Otol. 1998;19(3):345-351 3) Tirelli G, Russolo M. 360-Degree canalith repositioning procedure for the horizontal canal. Otolaryngol Head Neck Surg. 2004 Nov;131(5):740-6. Page 2 of 3

Right Geotropic Horizontal Canal BPPV SYMPTOM: Nystagmus is greater when affected (right) ear is in the downward position TREATMENT: Lempert 360º roll to the LEFT NYSTAGMUS: Should beat toward the LEFT throughout the entire procedure IMPLICATION: Pathological localization is generally in the utricle of the effected ear Left Geotropic Horizontal Canal BPPV SYMPTOM: Nystagmus is greater when affected (left) ear is in the downward position TREATMENT: Lempert 360º roll to the RIGHT NYSTAGMUS: Should beat toward the RIGHT throughout the entire procedure IMPLICATION: Pathological localization is likely in the utricle of the affected ear. Right Apogeotropic Horizontal Canal BPPV SYMPTOM: Nystagmus is greater when affected (right) ear is in the upward position TREATMENT: Convert nystagmus from apogeotropic to geotropic by using one of the methods listed below IMPLICATION: Pathological localization is likely in the horizontal canal of the affected ear Left Apogeotropic Horizontal Canal BPPV SYMPTOM: Nystagmus is greater when affected (left) ear is in the upward position TREATMENT: Convert nystagmus from apogeotropic to geotropic by using one of the methods listed below IMPLICATION: Pathological localization is likely in the horizontal canal of the affected ear Conversion Methods for Apogeotropic Horizontal Canal BPPV Head Thrust Modified Guffoni Vannucchi -Asprella Forced Prolonged Positioning Page 3 of 3

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Gufoni Maneuver for Left Lateral Canal BPPV Start with patient sitting up Rapidly move to a Side-lying position Quickly position head at a 45 degree angle with nose pointing down Helpful Hints: Before performing any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If any possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. This procedure is an alternative treatment for patients who cannot complete the Lempert 360º Roll. Page 1 of 2

Procedure: Begin with the patient sitting on the edge of the examination table, facing the examiner. With a rapid motion, guide the patient into a side-lying position toward the affected side. While the patient is lying on his side, with a quick movement, turn the patient s head to a 45º angle (so that the patient s nose is pointing toward the table). Hold this position for 2-3 minutes. Guide the patient back into a sitting position. References: 1) Gufoni M, Mastrosimone I, DiNasso F. Repositioning maneuver in benign paroxysmal positional vertigo of the horizontal semicircular canal. Acta Otorhinolaryngol Ital 1998;18:363-7 2) Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otology and Neurology 22:66-69, 2001 3) Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613. Page 2 of 2

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Vannucchi-Asprella Maneuver for Right Lateral Canal BBPV (may also be used for converting apogeotropic nystagmus to geotropic) Begin with patient seated lengthwise on the table Guide the patient to supine position Immediately rotate head away from the affected ear Rapidly return to sitting and repeat exercise Page 1 of 2

Helpful HInts: This maneuver may be used to convert apogeotropic nystagmus to geotropic nystagmus. If conversion is done successfully, the Lempert 360º Roll away from the affected side can be done to further remediate lateral canal BPPV. This maneuver requires brisk head movements and may not be well-tolerated by elderly patients. Before performing positioning maneuvers, it is important to ascertain whether the patient has current or past injuries of the neck or spine. It is most helpful to utilize Frenzel lenses or VNG while performing CRT. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus. If any possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. Procedure: Have the patient sit length-wise on the examination table. With rapid motion, guide the patient into a supine position and immediately rotate the patient s head away from the affected ear. While maintaining the turned head position, guide the patient back into a length-wise sitting position. Repeat 6-8 times in rapid succession. References: 1) Vannucchi P, Asprella Libonati G, Gufoni M. Therapy of lateral semicircular canal canalithiasis. Audiological Medicine 2005;3:52-56. 2) White JA, Coale KD, Catalano PJ, Oas JG. Diagnosis and management of horizontal semicircular canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2005;133:278-284. 3) CiniglioAppiani G, Gagliardi M, Magliulo G. Physical treatment of horizontal canal benign positional vertigo. Eur Arch Otorhinolaryngol. 1997;254(7):326-8 Page 2 of 2

Quick Guide Vestibular Diagnosis and Treatment A Physical Therapy Approach Brandt-Daroff Exercises (used in the treatment of posterior canal BPPV) With assistance Without assistance Helpful Hints: Before recommending any form of positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine. If possible neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure IMMEDIATELY and refer for a neurological evaluation. These symptoms might include: blurred vision, numbness, weakness of the arms or legs or confusion. In order for the exercise to be successful, the patient MUST remain in each position until the vertigo subsides PLUS an additional 30 seconds and the patient must perform all 10 revolutions of the exercise. This is time consuming and often traumatic for the patient due to intense vertigo. Therefore, it is vital that the patient is educated on what to expect during the exercise and has agreed to full compliance. Without the patient s commitment to full compliance, performing the Brandt-Daroff exercises might actually be counter-productive in that otoconia may travel to different parts of the vestibular system and cause a worsening of symptoms. You should instruct the patient that if they are doing the exercise properly, their symptoms will likely lessen in severity with each repetition. However, they should always do the full set of 10 complete revolutions. Page 1 of 2

Procedure: Begin with the patient sitting on his bed. The patient will turn his head 45º toward either side. The patient moves from sitting position to side-lying position while maintaining the 45º angle of the head (the patient s nose should be pointed upward). The patient lies in this position until his symptoms have subsided PLUS as additional 30 seconds. The patient returns to the sitting position and waits for symptoms to subside PLUS an additional 30 seconds. The patient should turn his head in the opposite direction and repeat the exercise. ** The above description constitutes one revolution of the exercise. It is recommended that the patient perform ten complete revolutions of the exercise, three times daily. References: 1) Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980 Aug;106(8):484-485 2) Fife TD, et al. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70(22): 2067 2074. Page 2 of 2